Mr Dalton’s letter refers to issues largely in two areas: the reporting of urgent care activity, and the reporting of activity from newer clinical pathways, such as ambulatory care services.

He indicated it was right that NHS Improvement had moved to address “long-standing lack of consistency” about how urgent care activity, so-called type 3 activity, (see box below for full definitions) was reported.

He also said: ”It is extremely important that local and national A&E data accurately reflects evolving clinical practices. We must also maintain the integrity of A&E attendance data, which is used to understand the pressures you are under, and ensure that we can understand and explain how this data has changed over time.

“We will be running a formal exercise from February to understand the detail of any new activity that may be submitted and how this fits with current guidance.”

Mr Dalton said: “Until the exercise above has been completed, I would ask that any new areas of activity that are already being included in your submission as a result of our October letter should be submitted as a separate return, starting with your January data return.

“We will be in touch shortly with more details of next steps…These will include a more detailed set of guiding principles outlining practices we would suggest can be adopted, to support you in your local decision-making and to help us understand the nature of any proposed changes.”

His letter said: ”Clinical practices in urgent and emergency care have evolved in recent years, and many of you offer new services that provide enormous benefits to patients in terms of their experience and the quality and timeliness of care they receive.

“We must ensure that these ‘new’ pathways for emergency care are appropriately reflected in local and national data. To do this, we need to collectively identify new pathways, assess local systems’ ability to measure the activity and waits associated with these pathways, and agree, based on a set of consistent principles, whether these should count towards the current A&E target.”

The regulator admitted at the time the move would give the performance figures a “small boost” – but insisted it was an attempt to ensure “consistency” rather than manipulate performance.

“Failure to [report all the A&E data from all pathways] results in data inconsistency and can also materially distort your performance, which will, therefore, not provide an accurate reflection of the service you are offering,” the letter said. It followed a move during 2017 to introduce new “GP streaming” at many more emergency departments.

However, recent developments illustrate NHSI’s move failed to to clear up uncertainty and inconsistency, and HSJ understands senior figures do not expect the issues to be easily resolved.

An NHS Improvement spokesman said: “We have communicated previously with trusts about variation in reporting A&E activity, and today’s letter seeks to provide greater clarity to trusts about how activity should be reported.

“It is very important that all emergency care pathways are appropriately recorded and that local and national data reflects the way that clinical practices in emergency care have evolved. We are committed to ensuring full transparency about activity and performance.”

What activity counts towards the four hour target?

NHS England’s guidelines for its A&E data collection says: “The weekly and monthly A&E attendances and emergency admissions collection collects the total number of attendances in the specified period for all A&E types, including minor injury units and walk-in centres, and of these, the number discharged, admitted or transferred within four hours of arrival.”

The 95 per cent four hour waiting time overall target is reported in three categories:

Type one departments provide 24 hour consultant led services with full resuscitation facilities and have designated accommodation for A&E patient.

Type three departments or urgent care centres: these comprise other types of A&E/MIUs/walk-in centres and urgent care centres. Type three departments can be doctor or nurse led. They can be co-located with a major A&E or in the community. NHS England guidance refers to “type four” centres, but data is only reported for overall activity and types one, two and three.

Overall: a figure combining all activity across all types of urgent and emergency care.

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